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BACKGROUND: Fecal microbiota transplantation (FMT) represents a new therapeutic option that has been studied in two randomized-controlled trials in ulcerative colitis patients. Our study aimed to identify patients' views on the use of this novel therapeutic approach. METHODS: Using an anonymous questionnaire, we obtained data from 574 inflammatory bowel disease (IBD) patients on their knowledge and willingness to undergo FMT. RESULTS: A large proportion of IBD patients (53.5%) are unaware that FMT is a therapeutic option in Clostridium difficile infection and potentially IBD. More responders preferred FMT (31.5%) to a study with a new medication (28.9%), although the difference was not significant (P=0.37), and the preferred way of transplantation was colonoscopy (49.7%). In all, 38.3% preferred a family member as a donor, but there was fear about the procedure (41.5% mentioned fear of infectious diseases, 26.5% expressed disgust). The knowledge of successful FMT treatment in other patients was important for 82.2% of responders and for 50.7%, a discussion with a specialist would likely change their opinion about FMT. CONCLUSION: FMT represents a therapeutic procedure that is of interest for IBD patients. As FMT has been receiving increasing interest as an alternative treatment in IBD and more studies on FMT in IBD are being carried out, it is important to learn about the knowledge, attitude, and preferences of patients to provide better education to patients on this topic. However, there are reservations because of the fact that data on the benefits of FMT in IBD are controversial and several limitations exist on the use of FMT in IBD.

With the adaption of virtual reality in the consumer space, spherical panorama photos are gaining popularity. Through wide-angle head-mounted displays, they can be experienced in a natural way and offer the user an immersive view of the captured scene. While being used in virtual reality, the alignment of the saved image does not matter much. However, when displaying the panorama on a 2D screen, the alignment can make a difference on how pleasant the image looks. We propose an automatic method to do lossless shifting of the image to make it look better on 2D screens.

With increasing spatial and temporal resolution in head-mounted displays (HMDs), using eye trackers to adapt rendering to the user is getting important to handle the rendering workload. Besides using methods like foveated rendering, we propose to use the current visual field for rendering, depending on the eye gaze. We use two effects for performance optimizations. First, we noticed a lens defect in HMDs, where depending on the distance of the eye gaze to the center, certain parts of the screen towards the edges are not visible anymore. Second, if the user looks up, he cannot see the lower parts of the screen anymore. For the invisible areas, we propose to skip rendering and to reuse the pixels colors from the previous frame. We provide a calibration routine to measure these two effects. We apply the current visual field to a renderer and get up to 2x speed-ups.

Non-celiac gluten sensitivity (NCGS) and emerging treatment options are hot topics in the celiac disease (CeD) scientific literature. However, very little is known about the perspective on these issues of CeD patients.We performed a large patient survey among unselected CeD patients in Switzerland.A total of 1689 patients were analyzed. 57.5% have previously heard of NCGS. 64.5% believe in the existence of this entity. Regarding a potential influence of NCGS on CeD awareness, 31.7% show a positive and 27.5% a negative perception. Patients with prior use of alternative medicine and women more often have heard of and believe in the existence of NCGS vs. those never having used alternative methods and men, respectively (66.9 vs. 56.9%, p=0.001 and 78.5 vs. 69.0%, p=0.001; 60.7 vs. 44.2%, p0.001 and 71.0 vs. 60.8%, p=0.002). Women and patients ≥30 years more often show a negative attitude towards NCGS (32.2% vs. 24.8%, p=0.024 and 32.2% vs. 24.2%, p=0.018). With regard to emerging treatment options for CeD, 43.3% have previously heard of novel agents, more women than men (46.0 vs. 38.0%, p=0.019).Perception of and attitude towards NCGS differ depending on sex, age and prior use of alternative medicine. Knowledge of the progress towards emerging treatment options is currently limited.

BACKGROUND There is insufficient data on diagnostic delay and associated factors in celiac disease (CeD) as well as on its potential impact on the course of disease. METHODS Specifically taking its two components - patients' and doctors' delay - into account, we performed a large systematic patient survey study among unselected CeD patients in Switzerland. RESULTS We found a mean/median total diagnostic delay of 87/24 months (IQR 5-96), with a range from 0 up to 780 months and roughly equal fractions of patients' and doctors' delay. Both mean/median total (93.1/24 vs. 60.2/12, p

Background: Irritable bowel syndrome (IBS) is a complex condition with multiple factors contributing to its aetiology and pathophysiology. Aetiologically these include genetics, life-time events and environment, and physiologically, changes in motility, central processing, visceral sensitivity, immunity, epithelial permeability and gastrointestinal microflora. Such complexity means there is currently no specific reliable biomarker for IBS, and thus IBS continues to be diagnosed and classified according to symptom based criteria, the Rome Criteria. Carefully phenotyping and characterisation of a ‘large’ pool of IBS patients across Europe and even the world however, might help identify sub-populations with accuracy and consistency. This will not only aid future research but improve tailoring of treatment and health care of IBS patients. Purpose: The aim of this position paper is to discuss the requirements necessary to standardize the process of selecting and phenotyping IBS patients and how to organise the collection and storage of patient information/samples in such a large multi-centre pan European/global study. We include information on general demographics, gastrointestinal symptom assessment, psychological factors, quality of life, physiological evaluation, genetic/epigenetic and microbiota analysis, biopsy/blood sampling, together with discussion on the organisational, ethical and language issues associated with implementing such a study. The proposed approach and documents selected to be used in such a study was the result of a thoughtful and thorough four-year dialogue amongst experts associated with the European COST action BM1106 GENIEUR (www.GENIEUR.eu). acceptedVersion

Virtual Reality has hit the consumer market with affordable head-mounted displays. When using these, it quickly becomes apparent that the resolution of the built-in display panels still needs to be highly increased. To overcome the resulting higher performance demands, eye tracking can be used for foveated rendering. However, as there are lens distortions in HMDs, there are more possibilities to increase the performance with smarter rendering approaches. We present a new system using optimizations for rendering considering lens astigmatism and combining this with foveated rendering through eye tracking. Depending on the current eye gaze, this delivers a rendering speed-up of up to 20%.

Catheter-based methods for multichannel intraluminal impedance-pH monitoring are invasive and uncomfortable. The current alternative is a wireless system that clips to the esophageal mucosa, but which only measures pH. A shorter two-site wireless sensor that detects impedance and pH, and can be clipped to the esophagus, would be desirable. This study compares sensor positions and separations to determine the optimal configuration of a two-site wireless sensor. Records of 20 patients (10 on and 10 off proton pump inhibitor) who had ambulatory reflux testing with a multichannel intraluminal impedance-pH system (Sandhill Scientific Inc., Highlands Ranch, CO, USA) with six impedance and two pH sensors were reviewed. An investigator was blinded to four combinations of impedance channels plus pH. He read a 3-hour postprandial section from each of the combinations (total of 80 studies) and marked reflux episodes. Results were compared with his own interpretation of the full tracing. Two hundred and two total reflux episodes were analyzed, 113 acid (pH 4). Mean and median numbers of total reflux episodes were calculated. In the full study, the interpreter detected a mean of 10 reflux episodes per study. In the 5 cm and 7 cm, 3 cm and 7 cm, and 3 cm and 5 cm studies, the interpreter found a mean of 8.1, 11.1, and 9.8 reflux episodes per study, respectively. One-way analysis of variance yielded a P-value of 0.43. The trend of these preliminary findings suggests that the 3 cm and 5 cm site is the most sensitive and the 5 cm and 7 cm is the least, with the 3 cm and 7 cm site perhaps as the preferred location. The lack of a significant difference, at the very least, suggests that any of the 'mini' locations could be used. The small number of observations could have resulted in a Type II statistical error.

Distal oesophageal spasm is a rare and under-investigated motility abnormality. Recent studies indicate effective bolus transit in varying percentages of distal oesophageal spasm patients.Explore functional aspects including contraction onset velocity and contraction amplitude cut-off values for simultaneous contractions to predict complete bolus transit.We re-examined data from 107 impedance-manometry recordings with a diagnosis of distal oesophageal spasm. Receiver operating characteristic analysis was conducted, regarding effects of onset velocity on bolus transit taking into account distal oesophageal amplitude and correcting for intra-individual repeated measures.Mean area under the receiver operating characteristic curve for saline and viscous swallows were 0.84±0.05 and 0.84±0.04, respectively. Velocity criteria of30 cm/s when distal oesophageal amplitude100 mmHg and 8 cm/s when distal oesophageal amplitude100 mmHg for saline and 32cm/s when distal oesophageal amplitude100 mmHg and7 cm/s when distal oesophageal amplitude100 mmHg for viscous had a sensitivity of 75% and specificity of 80% to identify complete bolus transit. Using these criteria, final diagnosis changed in 44.9% of patients. Abnormal bolus transit was observed in 50.9% of newly diagnosed distal oesophageal spasm patients versus 7.5% of patients classified as normal. Distal oesophageal spasm patients with distal oesophageal amplitude100 mmHg suffered twice as often from chest pain than those with distal oesophageal amplitude100 mmHg.The proposed velocity cut-offs for diagnosing distal oesophageal spasm improve the ability to identify patients with spasm and abnormal bolus transit.

Extraesophageal (EE) symptoms such as cough and throat clearing are common in patients referred for reflux testing, but are less commonly associated with gastroesophageal reflux disease (GERD). Patients with reflux associated EE symptoms often lack typical GERD symptoms of heartburn and regurgitation. Our aim was to compare the frequency of proximal esophageal reflux between esophageal (typical) symptoms and EE (atypical) symptoms. Combined multichannel intraluminal impedance-pH (MII-pH) tracings were blinded by an investigator so that symptom markers were relabeled with a number without disclosure of symptom type. We selected 40 patients with at least five reflux-related symptom events for one of four symptoms (heartburn, regurgitation, cough, or throat clearing). A blinded investigator analyzed all 200 reflux episodes, reporting the proximal esophageal extent of the reflux for all symptoms. The percentage of symptom-related reflux extending proximally to 17 cm above the LES was similar among all four symptom types. At least 50% of all symptoms were associated with proximal esophageal reflux to 17 cm, with regurgitation having the highest frequency at 60%. Our data indicate that EE symptoms are not more frequently associated with proximal esophageal reflux than typical esophageal symptoms.

Greenhouses in Turkey under integrated pest management can be colonized by a high number predatory flies of the species Coenosia attenuata Stein, 1903 (Muscidae: Coenosia Meigen, 1826). Studies have shown that Coenosia predators do not simply colonize greenhouses from the outside for short periods but instead they are able to complete their developmental cycle in the greenhouse soil and can become established there for a long period of time. C. attenuata is indigenous to the Palaeotropical region. Its prey spectrum includes whiteflies, black fungus gnats and leaf-mining flies. Studies of the natural occurrence of these predaceous flies in greenhouses led to a recognition of the significance of this complex of beneficials for the control of important greenhouse pests. They can build up effective populations under greenhouse conditions, and as non-specific predators can feed on a variety of pest groups and on innocuous species.

Aliment Pharmacol Ther 2011; 34: 476–486 Summary Background Limited data are available regarding the frequency of oesophageal motility and bolus transit abnormalities in subgroups of patients with gastro-oesophageal reflux disease (GERD). Aim To assess oesophageal motility and bolus transit in endoscopically defined GERD subgroups. Methods Patients (N = 755) with typical reflux symptoms underwent upper endoscopy, conventional or impedance oesophageal manometry and/or impedance-pH testing. They were divided into: erosive oesophagitis (EO; N = 340), Barrett Oesophagus (BO; N = 106), non-erosive reflux disease (NERD; endoscopy−, abnormal pH and/or SAP/SI+; N = 239) and functional heartburn (FH; endoscopy−, normal pH and SAP/SI−; N = 70). Manometric patterns and bolus transit were defined according to previously published criteria. Results Increasing GERD severity was associated with decreased lower oesophageal sphincter resting pressure (P < 0.05) and distal oesophageal amplitude (P

Patients with irritable bowel syndrome (IBS) have an increased response of postprandial symptoms to a combined lactulose nutrient challenge test, compared with healthy volunteers. We investigated the associations among comorbid functional dyspepsia (FD), severity of psychologic symptoms, and breath test results in response to this test.We performed a prospective study of 205 patients with IBS (Rome III criteria), 94 of whom also had FD (IBS-FD), and 83 healthy volunteers in Sweden from 2008 through 2015. All participants completed a breath hydrogen test after a 400-mL liquid meal with 25 g lactulose. Gastrointestinal (GI) symptom severity was assessed using a graded scale and digestive comfort was recorded before the meal and every 15 minutes until 240 minutes after the meal. GI symptom scores over time were compared between groups using linear mixed models with anxiety, depression, and somatization as covariates.Average levels of all GI symptoms varied over time among all groups (P.0001). Patients with IBS-FD had higher levels of bloating (P = .004), abdominal pain (P = .005), and lower levels of digestive comfort (P.01) than patients with only IBS. We observed a difference in increase in abdominal pain from baseline between IBS-FD and IBS groups (P = .013). Anxiety levels were associated with levels of all symptoms (all P.025) except abdominal pain, which was associated with somatization severity (P.0001). Furthermore, anxiety levels associated with level of exhaled hydrogen (P = .0042).In a prospective study of patients with IBS, we found those with FD to have increased GI symptoms before and after a liquid meal with lactulose. Anxiety and somatization have an independent additional effect. The presence of comorbid FD and levels of psychologic symptoms affect reports of food-related symptoms in patients with IBS. ClinicalTrial.gov no: NCT01252550.

Background Joint hypermobility syndrome (JHS) is characterized by excessive connective tissue laxity manifest as joint hypermobility (JH) together with musculoskeletal symptoms. Previous studies have shown an association between JH/JHS and gastrointestinal symptoms, including irritable bowel syndrome (IBS), although its association with specific IBS subtypes is incompletely understood. We aimed to determine the prevalence of JH according to the subtypes of IBS, in particular IBS-C and IBS-D. Methods Data of 228 consecutive IBS patients were analyzed. IBS was subtyped into constipation and diarrhea predominant IBS (IBS-C and IBS-D), IBS with mixed bowel habits (IBS-M) and unsubtyped IBS (IBS-U). JH was defined as a Beighton Score ≥4/9 points and JHS diagnosed according to revised Brighton Criteria. Data of IBS patients were analyzed for psychological comorbidities assessed by Hospital Anxiety and Depression Scale (HADS) and Visceral Sensitivity Index (VSI). Key results Of 228 IBS patients, 64 (28.1%) suffered from IBS-C, 89 (39.0%) from IBS-D, 48 (21.1%) from IBS-M, and 27 (11.8%) from IBS-U. JH was diagnosed in 95 patients (41.7%). The prevalence of JH was significantly higher in IBS-C than IBS-D (57.8% vs 34.8%, P = .031). There was no significant difference in VSI and HADS according to JH or IBS subtype. Conclusions and interferences The prevalence of JH was significantly higher in IBS-C compared to IBS-D. Abnormalities in the connective tissue biomechanics in those with JH may contribute to a degree of colonic inertia which could result in constipation in JH-positive IBS patients. Further work is needed to determine the colonic biomechanics in patients with JH.

Constipation is a common gastrointestinal disease affecting 2-27% of the population in Western hemisphere. Approximately in half of patients the diagnosis of functional constipation is made after having ruled out secondary causes. Treatment of chronic functional constipation primarily addresses education on toilet habits, dietary advice, and patient reassurance. Further therapies are guided according to functional subtype slow-transit constipation, dyssynergic defecation, and constipation-predominant irritable bowel syndrome (IBS-C). Traditionally, the pharmacologic treatment of constipation uses primarily bulking agents and/or laxatives (osmotic or secretory). However, often these therapies do not provide the desired improvement, have a short-lived efficacy and/or are accompanied by side-effects such as bloating and abdominal cramps. Thus, there is a clinical need for new, more potent drugs particularly for patients who are not satisfactorily treated by conventional therapies. This review discusses recent developments in the pharmacologic treatment of chronic constipation including recently FDA-approved lubiprostone, emerging 5-HT receptors modifiers, investigational substances, and probiotics.

Summary Background Lactase deficiency is a common condition responsible for various abdominal symptoms. Lactose hydrogen breath test is currently the gold standard in diagnosing lactose intolerance. Aim To assess sensitivity and specificity of symptoms developed after oral lactose challenge. Methods Intensity of nausea, abdominal pain, borborygmi, bloating and diarrhoea was recorded every 15 min up to 3 h after ingestion of 50 g lactose in patients with positive (i.e. breath H2-concentration ≥20 p.p.m. above baseline) and negative lactose hydrogen breath test. Results Between July 1999 and December 2005, 1127 patients (72% females) underwent lactose hydrogen breath test. A positive result was found in 376 (33%). Sensitivity of individual symptoms ranged from 39% (diarrhoea) to 70% (bloating) while specificity ranged from 69% (bloating) to 90% (diarrhoea). A positive lactose hydrogen breath test was found in 21% of patients with one symptom, 40% of patients with two symptoms, 44% of patients with three symptoms, 67% of patients with four symptoms and 82% of patients with five symptoms. Symptom intensity was significantly higher for each symptom in the positive group. Conclusion Evaluating symptoms developed after ingestion of 50 g lactose can be used as a simple screening test to select patients who need to be referred for lactose intolerance testing.

BACKGROUND: Many patients complain of abdominal symptoms with dairy products; however, clinical and psychosocial factors associated with self-reported lactose intolerance (SLI) have not been assessed in large studies. In particular, data are lacking from lactase deficient populations. This prospective cohort study assessed the prevalence of, and risk factors for, SLI in Chinese patients attending a gastroenterology clinic. METHODS: Consecutive patients completed questionnaires to assess digestive health (Rome III), psychological state (HADS), life event stress (LES), food intake, and quality-of-life (SF-8). A representative sample completed genetic studies and hydrogen breath testing (HBT) at the clinically relevant dose of 20 g lactose. KEY RESULTS: SLI was present in 411/910 (45%) clinic patients with functional abdominal symptoms. The genotype in all subjects was C/C-13910. A small number of novel SNPs in lactase promoter region were identified, including C/T-13908 which appeared to confer lactase persistence. Over half of the patients (54%) completed the 20 g lactose HBT with 58% (285/492) reporting typical symptoms. Positive and negative predictive values of SLI for abdominal symptoms during HBT were 60% and 44%, respectively. Psychological state and stress were not associated with SLI in clinic patients. SLI impacted on physical quality-of-life and was associated with reduced ingestion of dairy products, legumes, and dried fruit (p ≤ 0.05). CONCLUSIONS & INFERENCES: In a lactase deficient population, approximately half of patients attending clinic with functional gastrointestinal symptoms reported intolerance to dairy products; however, SLI did not predict findings on 20 g lactose HBT. Independent of psychosocial factors, SLI impacted on quality-of-life and impacted on food choices with restrictions not limited to dairy products.

The study investigated the effect of soil application of neem at different concentrations on lifetable parameters of Myzus persicae (Sulzer) (Hemiptera: Aphididae). After pepper seedlings were transplanted to pots of 1.5 L, the pepper plants had been divided into five different groups to be watered with only irrigation water (as control) and irrigation water containing 250, 500, 750 and 1000 mg L-1 of neem. Based on the results, intrinsic rate of increase (rm), net production rate (R0) and mean generation time (T0) ranged from 0.039 to 0.352 female/female/day, 1.700 to 57.295 female/female and 11.503 to 15.086 days respectively. Doubling time (T2) and finite rate of increment (λ) ranged from 1.970 to 17.915 days and 1.039 to 1.422 individual/female/day, respectively. Consequently, the effect of neem on biological characters of the pest was increased in response to the increase in neem concentration applied systemically through plant root.

Lenses in modern consumer HMDs introduce distortions like astigmatism: only the center area of the displayed content can be perceived sharp while with increasing distance from the center the image gets out of focus. We show with three new approaches that this undesired side effect can be used in a positive way to save calculations in blurry areas. For example, using sampling maps to lower the detail in areas where the image is blurred through astigmatism, increases performance by a factor of 2 to 3. Further, we introduce a new calibration of user-specific viewing parameters that increase the performance by about 20–75%.

AIM: To validate 4-sample lactose hydrogen breath testing (4SLHBT) compared to standard 13-sample LHBT in the clinical setting. METHODS: Irritable bowel syndrome patients with diarrhea (IBS-D) and healthy volunteers (HVs) were enrolled and received a 10 g, 20 g, or 40 g dose lactose hydrogen breath test (LHBT) in a randomized, double-blinded, controlled trial. The lactase gene promoter region was sequenced. Breath samples and symptoms were acquired at baseline and every 15 min for 3 h (13 measurements). The detection rates of lactose malabsorption (LM) and lactose intolerance (LI) for a 4SLHBT that acquired four measurements at 0, 90, 120, and 180 min from the same data set were compared with the results of standard LHBT. RESULTS: Sixty IBS-D patients and 60 HVs were studied. The genotype in all participants was C/C-13910. LM and LI detection rates increased with lactose dose from 10 g, 20 g to 40 g in both groups (P < 0.001). 4SLHBT showed excellent diagnostic concordance with standard LHBT (97%-100%, Kappa​​ 0.815-0.942) with high sensitivity (90%-100%) and specificity (100%) at all three lactose doses in both groups. CONCLUSION: Reducing the number of measurements from 13 to 4 samples did not significantly impact on the accuracy of LHBT in health and IBS-D. 4SLHBT is a valid test for assessment of LM and LI in clinical practice.

Background Airway hyperresponsiveness and inflammation can be noninvasively studied by bronchial provocation using direct (histamine) or indirect (adenosine 5′-monophosphate [AMP]) stimuli and induced sputum. Objective To report on the immediate effects of histamine and AMP challenge on induced sputum neutrophil counts and related mediator levels. Methods We performed a single-masked, randomized, placebo-controlled, 3-way, crossover, methodological study in 14 atopic patients (median age, 25 years; 8 males; mean ± SD forced expiratory volume in 1 second, 99% ± 5%) without anti-inflammatory medication use. At baseline, sputum induction was performed. Bronchial challenges with AMP, histamine, or placebo were performed 48 hours later. Thirty minutes after challenge, sputum induction was performed again. Challenge periods in each patient were separated by more than 2 weeks. Sputum cells and the mediators leukotriene B 4 , interleukin 8, myeloperoxidase, and albumin were quantified. Results Comparing median challenge-induced relative changes in cells and mediators, neither histamine nor AMP challenge altered the induced sputum neutrophil counts (histamine, 2.7%; AMP, 2.95%; placebo, −2%; P > .07 for all), interleukin 8 levels (histamine, 2.4 ng/mL; AMP, −3.8 ng/mL; placebo, −0.2 ng/mL; P > .06), leukotriene B 4 levels (histamine, −4.8 pg/mL; AMP, 3 pg/mL; placebo, 6 pg/mL; P > .08), or myeloperoxidase levels (histamine, 0.16 μg/mL; AMP, 0 μg/mL; placebo, −0.03 μg/mL; P > .07). Sputum albumin levels were increased after histamine challenge compared with AMP and placebo challenge ( P Conclusions Histamine and AMP provocation have no major effects on induced neutrophil counts and related mediator levels in atopic patients, whereas histamine challenge induces plasma leakage. Potential interactions of noninvasive methods to evaluate airway reactivity and inflammation should be carefully considered.

The occurrence of the predatory fly Coenosia attenuata (Stein, 1903) is reported for the first time in Turkey. The population dynamics of the fly in irrigated cotton fields in the eastern Mediterranean region of Turkey is described, and the role of C. attenuata as a biological control agent in the agroecosystem is discussed.

GOALS We aim to look at the prevalence of multichannel intraluminal impedance-pH (MII-pH) studies, which are difficult to interpret secondary to low distal baseline impedance (DBI), and characterize them by their respective diagnosis and DBI. BACKGROUND Some patients exhibit low DBI because of fluid retention in the esophagus or acute or chronic mucosal changes. Low DBI can make MII-pH difficult to interpret. STUDY We reviewed MII-pH reports from patients studied from January 2002 to December 2009. We conducted a computerized search of the final interpretation for the terms "low," "low baseline," "difficult," and "unable." Reflux reports stating difficult or unable to interpret were analyzed. The associated manometry studies were reviewed to obtain the DBI (mean value at 5 and 10 cm above the lower esophageal sphincter in the pretest esophageal resting state). RESULTS Of 2809 MII-pH tracings, 38 (1.4%) were classified as difficult to interpret because of low DBI. The most common underlying manometric diagnosis was ineffective esophageal motility at 36.8%, followed by 28.9% with achalasia, and 10.5% with scleroderma esophagus. An additional 15.8% of patients had increased gastroesophageal reflux on MII-pH. In only 7.9% of patients was no obvious reason for the low DBI identified. Of the 38 patients, 92% had a DBI

Here, we present a case of a 50-year-old male with a history of a Guillain-Barré-syndrome, who was referred to our clinic with recurrent esophageal candidiasis and long-standing intermittent retrosternal cramps for further evaluation. Other symptoms such as dysphagia, regurgitations and weight loss were denied, and prior repeated endoscopy was otherwise unremarkable. Using high resolution impedance manometry, we could demonstrate a panesophageal pressure increase on water swallows and complete aperistalsis of the tubular esophagus, indicating achalasia type II. However, due to the patient’s extraordinary body height and resulting length of the esophagus, endoluminal functional lumen imaging probe analysis supplementary to high resolution impedance manometry needed to be used to assess distensibility of the esophagogastral junction and to secure the diagnosis of achalasia before appropriately treating the patient with pneumatic dilation.

High-quality head mounted displays are becoming available in the consumer space. These displays provide an immersive gaming experience by filling the wearer's field of view. To achieve immersion with low cost, a commodity display panel is placed a short distance in front of each eye, and wide-angle optics are used to bring the image into focus. However, these optics introduce spatial and chromatic distortion into the image seen by the viewer. As a result, the images to be displayed must be pre-warped to cancel this distortion. This correction can be performed by warping the image in a post-processing step, by warping the scene geometry before rendering, or by modeling corrective optics in the virtual camera.Here, we examine the image quality and performance of several correction methods. Though image warping with a bilinear filter is common [Antonov et al. 2013], we find that bicubic filtering yields improved image quality with minimal performance impact. We also propose a new method for correcting chromatic distortion by warping the image using distortion meshes, and we propose a method for correcting spatial and chromatic distortion accurately in-camera.

INTRODUCTION: Voluntary muscle activity, including swallowing, decreases during the night. The association between nocturnal awakenings and swallowing activity is under-researched with limited information on the frequency of swallows during awake and asleep periods. AIM: The aim of this study was to assess nocturnal swallowing activity and identify a cut-off predicting awake and asleep periods. METHODS: Patients undergoing impedance-pH monitoring as part of GERD work-up were asked to wear a wrist activity detecting device (Actigraph(®)) at night. Swallowing activity was quantified by analysing impedance changes in the proximal esophagus. Awake and asleep periods were determined using a validated scoring system (Sadeh algorithm). Receiver operating characteristics (ROC) analyses were performed to determine sensitivity, specificity and accuracy of swallowing frequency to identify awake and asleep periods. RESULTS: Data from 76 patients (28 male, 48 female; mean age 56 ± 15 years) were included in the analysis. The ROC analysis found that 0.33 sw/min (i.e. one swallow every 3 min) had the optimal sensitivity (78 %) and specificity (76 %) to differentiate awake from asleep periods. A swallowing frequency of 0.25 sw/min (i.e. one swallow every 4 min) was 93 % sensitive and 57 % specific to identify awake periods. A swallowing frequency of 1 sw/min was 20 % sensitive but 96 % specific in identifying awake periods. Impedance-pH monitoring detects differences in swallowing activity during awake and asleep periods. Swallowing frequency noticed during ambulatory impedance-pH monitoring can predict the state of consciousness during nocturnal periods

Lactose malabsorption is a common condition caused by reduced expression or activity of lactase in the small intestine. In such patients, lactose intolerance is characterized by abdominal symptoms (e.g. nausea, bloating, and pain) after ingestion of dairy products. The genetic basis of lactose malabsorption is established and several tests for this condition are available, including genetic, endoscopic, and H2-breath tests. In contrast, lactose intolerance is less well understood. Recent studies show that the risk of symptoms after lactose ingestion depends on the dose of lactose, lactase expression, intestinal flora, and sensitivity of the gastrointestinal tract. Lactose intolerance has recently been defined as symptoms developing after ingestion of lactose which do not develop after placebo challenge in a person with lactose maldigestion. Such blinded testing might be especially important in those with functional gastrointestinal diseases in whom self-reported lactose intolerance is common. However, placebo-controlled testing is not part of current clinical practice. Updated protocols and high-quality outcome studies are needed. Treatment options of lactose intolerance include lactose-reduced diet and enzyme replacement. Documenting the response to multiple doses can guide rational dietary management; however, the clinical utility of this strategy has not been tested. This review summarizes the genetic basis, diagnosis, and treatment of lactose malabsorption and intolerance.

Symptom association is important to distinguish non-erosive reflux disease [NERD; abnormal oesophageal acid exposure time (AET) and/or positive symptom association] from functional heartburn (FH; normal AET and negative symptom association). Asymptomatic patients during reflux monitoring are challenging as symptom association cannot be assessed. To evaluate whether impedance-pH reflux patterns are useful to differentiate NERD from FH. Endoscopy-negative reflux patients underwent impedance-pH off-therapy. Oesophageal AET, characteristics of reflux episodes and symptom association probability (SAP) were measured. Twenty patients asymptomatic during the first test repeated a second examination. Of 329 patients, 130 (40%) were pH-POS, 120 (36%) pH-NEG/SAP+ (hypersensitive oesophagus = HO) and 79 (24%) pH-NEG/SAP− (FH). Total and acid reflux episodes were significantly higher (p

The following on proton pump inhibitors (PPIs) and chemoprevention in relation to Barrett's esophagus includes commentaries on 48-h pH monitoring, pH-impedence, bile acid testing, dyspepsia, long/short segment Barrett's esophagus, nonerosive reflux disease (NERD), functional heartburn, dual-release delivery PPIs, immediate-release PPIs, long-term PPI use, prokinetic agents, obesity, baclofen, nocturnal acid breakthrough, nonsteroidal anti-inflammatory drugs (NSAIDs), and new PPIs.

Objectives: We describe the spectrum of findings and the diagnostic value of MR defecography in patients referred with suspicion of dyssynergic defecation. Methods: 48 patients (34 females, 14 males; mean age 48 years) with constipation and clinically suspected dyssynergic defecation underwent MR defecography. Patients were divided into patients with dyssynergic defecation (n518) and constipated patients without dyssynergic defecation (control group, n530). MRIs were analysed for evacuation ability, time to initiate evacuation, time of evacuation, changes in the anorectal angle (ARA-change), presence of paradoxical sphincter contraction and presence of additional pelvic floor abnormalities. Sensitivity, specificity, positive and negative predictive values and accuracy for the diagnosis of dyssynergic defecation were calculated. Results: The most frequent finding was impaired evacuation, which was seen in 100% of patients with dyssynergic defecation and in 83% of the control group, yielding a sensitivity for MR defecography for the diagnosis of dyssynergic defecation of 100% (95% confidence interval (CI) 97–100%), but a specificity of only 23% (95% CI 7–40%). A lower sensitivity (50%; 95% CI 24–76%) and a high specificity (97%; 95% CI 89–100%) were seen with abnormal ARA-change. The sensitivity of paradoxical sphincter contraction was relatively high (83%; 95% CI 63–100%). A combined analysis of abnormal ARA-change and paradoxical sphincter contraction allowed for the detection of 94% (95% CI 81–100%) of the patients with dyssynergic defecation. Conclusion: MR defecography detects functional and structural abnormal findings in patients with clinically suspected dyssynergic defecation. Impaired evacuation is seen in patients with functional constipation owing to other pelvic floor abnormalities than dyssynergic defecation.

Clinical manifestations of lactase (LCT) deficiency include intestinal and extra-intestinal symptoms. Lactose hydrogen breath test (H2-BT) is considered the gold standard to evaluate LCT deficiency (LD). Recently, the single-nucleotide polymorphism C/T− 13 910has been associated with LD. The objectives of the present study were to evaluate the agreement between genetic testing of LCT C/T− 13 910and lactose H2-BT, and the diagnostic value of extended symptom assessment. Of the 201 patients included in the study, 194 (139 females; mean age 38, range 17–79 years, and 55 males, mean age 38, range 18–68 years) patients with clinical suspicion of LD underwent a 3–4 h H2-BT and genetic testing for LCT C/T− 13 910. Patients rated five intestinal and four extra-intestinal symptoms during the H2-BT and then at home for the following 48 h. Declaring H2-BT as the gold standard, the CC− 13 910genotype had a sensitivity of 97 % and a specificity of 95 % with a κ of 0·9 in diagnosing LCT deficiency. Patients with LD had more intense intestinal symptoms 4 h following the lactose challenge included in the H2-BT. We found no difference in the intensity of extra-intestinal symptoms between patients with and without LD. Symptom assessment yielded differences for intestinal symptoms abdominal pain, bloating, borborygmi and diarrhoea between 120 min and 4 h after oral lactose challenge. Extra-intestinal symptoms (dizziness, headache and myalgia) and extension of symptom assessment up to 48 h did not consistently show different results. In conclusion, genetic testing has an excellent agreement with the standard lactose H2-BT, and it may replace breath testing for the diagnosis of LD. Extended symptom scores and assessment of extra-intestinal symptoms have limited diagnostic value in the evaluation of LD.

We sought to compare reflux and symptom association patterns in patients with nonerosive reflux disease (NERD), erosive esophagitis (EE), and in healthy volunteers (HVs).Patients with EE and NERD underwent combined impedance-pH monitoring. Normal values were defined on the basis of previously collected data from 48 HVs. We evaluated distal esophageal acid exposure time (AET), number and type of reflux episodes (acid, nonacid), acid and bolus clearance times, proximal extension of reflux episodes, and symptom association probability (SAP).Distal AET (percentage time, pH4) was higher (P0.01) in 58 EE patients (median 7.4%, 25-75th percentile 4.2-9.9%) compared with 168 NERD patients (4.2% (1.2-6.4%)) and 48 HVs (0.7% (0.2-1.4%)). Patients with EE and NERD had a higher (P0.01) number of acid reflux episodes compared with HVs (51 (37-66) vs. 34 (22-51) vs. 17 (8-31); P0.05), but a similar number of nonacid reflux episodes (22 (15-39) vs. 23 (15-38) vs. 18 (14-26); P=NS). The percentage of reflux episodes reaching the proximal esophagus was higher (P0.01) in EE patients (57% (45-73%)) than in NERD patients (45% (36-60%)) and HVs (33% (19-46%)). A positive SAP for heartburn or regurgitation was found in 161 of 168 (96%) NERD and 54 of 58 (93%) EE patients (P=NS).Acid reflux episodes, volume, and acid clearance are important factors in the pathogenesis of reflux-induced lesions. Nonacid reflux contributes less to esophageal mucosa damage, but is involved in the development of reflux symptoms in both NERD and EE patients.

Interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) is associated with increased morbidity and mortality. Gastroesophageal reflux (GER) is considered a contributing factor in the pathogenesis of ILD.To characterize GER (acid and nonacid) in patients with SSc with and without ILD.Patients with SSc underwent pulmonary high-resolution computer tomography (HRCT) scan and 24-hour impedance-pH monitoring off-proton pump inhibitor therapy. The presence of pulmonary fibrosis was assessed using validated HRCT-scores. Reflux monitoring parameters included number of acid and nonacid reflux episodes, proximal migration of the refluxate, and distal esophageal acid exposure. Unless otherwise specified, data are presented as median (25th-75th percentile).Forty consecutive patients with SSc (35 female; mean age, 53 yr; range, 24-71; 15 patients with diffuse and 25 with limited SSc) were investigated; 18 (45%) patients with SSc had pulmonary fibrosis (HRCT scoreor= 7). Patients with SSc with ILD had higher (P0.01) esophageal acid exposure (10.3 [7.5-15] vs. 5.2 [1.5-11]), higher (P0.01) number of acid (41 [31-58] vs. 19 [10-23]) and nonacid (25 [20-35] vs. 17 [11-19]) reflux episodes, and higher (P0.01) number of reflux episodes reaching the proximal esophagus (42.5 [31-54] vs. 15 [8-22]) compared with patients with SSc with normal HRCT scores. Pulmonary fibrosis scores (HRCT score) correlated well with the number of reflux episodes in the distal (r(2) = 0.637) and proximal (r(2) = 0.644) esophagus.Patients with SSc with ILD have more severe reflux (i.e., more reflux episodes and more reflux reaching the proximal esophagus). Whether or not the development of ILD in patients with SSc can be prevented by reflux-reducing treatments needs to be investigated.

Introduction: Functional dyspepsia and non-erosive reflux disease (NERD) are prevalent gastrointestinal conditions with accumulating evidence regarding an overlap between the two. Still, patients with NERD represent a very heterogeneous group and limited data on dyspeptic symptoms in various subgroups of NERD are available. Aim: To evaluate the prevalence of dyspeptic symptoms in patients with NERD subclassified by using 24 h impedance-pH monitoring (MII-pH). Methods: Patients with typical reflux symptoms and normal endoscopy underwent impedance-pH monitoring off proton pump inhibitor treatment. Oesophageal acid exposure time (AET), type of acid and non-acid reflux episodes, and symptom association probability (SAP) were calculated. A validated dyspepsia questionnaire was used to quantify dyspeptic symptoms prior to reflux monitoring. Results: Of 200 patients with NERD (105 female; median age, 48 years), 81 (41%) had an abnormal oesophageal AET (NERD pH-POS), 65 (32%) had normal oesophageal AET and positive SAP for acid and/or non-acid reflux (hypersensitive oesophagus), and 54 (27%) had normal oesophageal AET and negative SAP (functional heartburn). Patients with functional heartburn had more frequent (p

Nonerosive reflux disease (NERD) is the most common form of gastroesophageal reflux disease. While the role of acid reflux has been established, the relevance of nonacid reflux in generating symptoms in NERD is unknown.To evaluate the diagnostic utility of impedance-pH monitoring in NERD patients.Patients with typical reflux symptoms (heartburn and/or regurgitation) and normal endoscopy (NERD) underwent a combined impedance-pH monitoring off proton pump inhibitor (PPI) therapy. Previously investigated 48 healthy volunteers served as controls. Distal esophageal acid exposure (% time pH4), number of acid and nonacid reflux episodes, 2-min window symptom index (SI; positive ifor = 50%), and symptom association probability (SAP; positive ifor = 95%) were calculated.Between June 2004 and June 2007, 150 NERD patients (82 women, mean age 48 yr, range 18-78 yr) reported symptoms during the impedance-pH monitoring. NERD patients had more reflux episodes (median [25th-75th percentile]) compared with healthy volunteers (total: 46 [26-65] vs 32 [18-43], P0.05; acid: 29 [14-43] vs 17 [8.5-31.0], P0.05; and nonacid: 20 [15-27] vs 18 [13.5-26.0], P = NS). Sixty-three (42%) patients had abnormal % time pH4. Among 87 patients with normal % time pH4., 22 (15%) had a positive SAP for acid, 19 (12%) for nonacid reflux, and 7 (5%) for both. Classifying patients with symptomatic nonacid reflux as having a hypersensitive esophagus reduced the number of patients with functional heartburn from 65 (43%) to 39 (26%).Monitoring for nonacid reflux in NERD patients reduces the proportion of patients classified as having "functional heartburn." Studies assessing the clinical implications of these findings are warranted.

Background Esophageal motility studies in humans have documented a low-pressure zone (LPZ) in the area of transition from striated to smooth muscle. While preliminary studies indicate that a bolus might be retained in this area, the clinical relevance of the LPZ remains unclear. Aim To investigate a possible relationship between esophageal symptoms and the size of the esophageal LPZ. Methods We reviewed high-resolution manometry (HRM) data from patients with esophageal symptoms (dysphagia, chest pain, and heartburn/regurgitation) and asymptomatic volunteers. The proximal border of the LPZ was defined as the point where the amplitude of the proximal contraction wave declined below 30 mmHg, and the distal border as the point where the distal contraction wave first increased above 30 mmHg. Results The average (+/- standard error of mean [SEM]) length of the LPZ in 44 asymptomatic individuals was 5.4 +/- 0.6 cm and did not differ (P= 0.222) from the LPZ in 64 patients with dysphagia (6.8 +/- 0.4 cm), 34 patients with chest pain (6.4 +/- 0.6 cm), and 42 patients with gastroesophageal reflux disease (GERD) symptoms (7.0 +/- 0.6 cm). These results did not change when the length of the LPZ was corrected for total esophageal length. The time width of the LPZ in asymptomatic individuals (1.6 +/- 0.2 s) was shorter than in patients with dysphagia and GERD symptoms (dysphagia 2.4 +/- 0.2 s, GERD symptoms 2.8 +/- 0.3 s). Conclusion A time delay between the proximal and distal esophageal contraction waves might be a meaningful variable in GERD and dysphagia.

Specific carbohydrates, i.e. prebiotics such as fructo-oligosaccharide (FOS), are not digested in the small intestine but fermented in the colon. Besides beneficial health effects of an enhanced bifidobacteria population, intestinal gas production resulting from fermentation can induce abdominal symptoms. Partial replacement with slowly fermented acacia gum may attenuate side effects. The aim was to compare the effects of FOS with those of a prebiotic mixture (50 % FOS and 50 % acacia gum; BLEND) and a rapidly absorbed carbohydrate (maltodextrin) on general intestinal wellbeing, abdominal comfort and anorectal sensory function. Twenty volunteers (eight male and twelve female; age 20–37 years) completed this double-blind, randomised study with two cycles of a 2-week run-in phase (10 g maltodextrin) followed by 5 weeks of 10 g FOS or BLEND once daily, separated by a 4-week wash-out interval. Abdominal symptoms and general wellbeing were documented by telephone interview or Internet twice weekly. Rectal sensations were assessed by a visual analogue scale during a rectal barostat test after FOS and BLEND treatment. Both FOS and BLEND induced more side effects than maltodextrin. Belching was more pronounced under FOS compared with BLEND (P = 0·09 for females; P = 0·01 for males), and for self-reported general wellbeing strong sex differences were reported (P = 0·002). Urgency scores during rectal barostat were higher with FOS than BLEND (P = 0·01). Faced with a growing range of supplemented food products, consumers may benefit from prebiotic mixtures which cause fewer abdominal side effects. Sex differences must be taken in consideration when food supplements are used.